<?xml version="1.0" encoding="UTF-8"?>
<table class="container" cellpadding="0" cellspacing="3">
  <tr>
    <td colspan="2" id="content"/>
  </tr>
  <tr>
    <td id="left">
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Oxígeno con MFL:</span>
        <span class="content">
          <select name="field_124">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Apoyo ventilatorio con B-V-M:</span>
        <span class="content">
          <select name="field_125">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Intubación orotraqueal:</span>
        <span class="content">
          <select name="field_126">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Máscara laringea:</span>
        <span class="content">
          <select name="field_127">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Vía aérea quirúrgica:</span>
        <span class="content">
          <select name="field_128">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Collar cervical:</span>
        <span class="content">
          <select name="field_129">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Empaquetado:</span>
        <span class="content">
          <select name="field_130">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Drenaje de neumotórax a tensión:</span>
        <span class="content">
          <select name="field_131">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Torniquete:</span>
        <span class="content">
          <select name="field_132">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_BOOLEAN ">
        <span class="label">Férulas en miembros:</span>
        <span class="content">
          <select name="field_133">
            <option value=""/>
            <option value="label.boolean.true">Si</option>
            <option value="label.boolean.false">No</option>
          </select>
        </span>
      </div>
      <div class="ELEMENT ELEMENT_DV_TEXT ">
        <span class="label">Inotrópicos prehospitalarios:</span>
        <span class="content">
          <textarea name="field_134"></textarea>
        </span>
      </div>
      <div class="CLUSTER  ">
        <span class="label">Sedación prehospitalaria:</span>
        <span class="content">
          <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
            <span class="label">Sedación:</span>
            <span class="content">
              <label class="id_Midazolám">
                <input type="radio" value="at0052||Midazolám" name="field_135"/>
Midazolám              </label>
              <label class="id_Morfina">
                <input type="radio" value="at0053||Morfina" name="field_135"/>
Morfina              </label>
              <label class="id_Pentotal">
                <input type="radio" value="at0054||Pentotal" name="field_135"/>
Pentotal              </label>
              <label class="id_Tramadol">
                <input type="radio" value="at0055||Tramadol" name="field_135"/>
Tramadol              </label>
              <label class="id_Meperidina">
                <input type="radio" value="at0056||Meperidina" name="field_135"/>
Meperidina              </label>
              <label class="id_Ketoprofeno">
                <input type="radio" value="at0057||Ketoprofeno" name="field_135"/>
Ketoprofeno              </label>
              <label class="id_nr">
                <input type="radio" checked="true" value="" name="field_135"/>
NR              </label>
            </span>
          </div>
          <div class="ELEMENT ELEMENT_DV_TEXT ">
            <span class="label">Otras drogas:</span>
            <span class="content">
              <textarea name="field_136"></textarea>
            </span>
          </div>
        </span>
      </div>
      <div class="ACTION  ">
        <span class="label">Resumen de actuación:</span>
        <span class="content">
          <div class="ELEMENT ELEMENT_DV_TEXT ">
            <span class="label">Diagnóstico / Actuación:</span>
            <span class="content">
              <textarea name="field_137"></textarea>
            </span>
          </div>
          <div class="ELEMENT ELEMENT_DV_DATE_TIME ">
            <span class="label">Fecha y Hora de evaluación:</span>
            <span class="content">
              <input type="hidden" name="field_138" value="date.struct"/>
              <select name="field_138_day" id="field_138_day">
                <option value="1">1</option>
                <option value="2">2</option>
                <option value="3">3</option>
                <option value="4">4</option>
                <option value="5">5</option>
                <option value="6">6</option>
                <option value="7">7</option>
                <option value="8">8</option>
                <option value="9">9</option>
                <option value="10">10</option>
                <option value="11">11</option>
                <option value="12">12</option>
                <option value="13">13</option>
                <option value="14">14</option>
                <option value="15">15</option>
                <option value="16">16</option>
                <option value="17">17</option>
                <option value="18">18</option>
                <option value="19">19</option>
                <option value="20">20</option>
                <option value="21" selected="selected">21</option>
                <option value="22">22</option>
                <option value="23">23</option>
                <option value="24">24</option>
                <option value="25">25</option>
                <option value="26">26</option>
                <option value="27">27</option>
                <option value="28">28</option>
                <option value="29">29</option>
                <option value="30">30</option>
                <option value="31">31</option>
              </select>
              <select name="field_138_month" id="field_138_month">
                <option value="1">January</option>
                <option value="2">February</option>
                <option value="3">March</option>
                <option value="4">April</option>
                <option value="5">May</option>
                <option value="6">June</option>
                <option value="7">July</option>
                <option value="8">August</option>
                <option value="9" selected="selected">September</option>
                <option value="10">October</option>
                <option value="11">November</option>
                <option value="12">December</option>
              </select>
              <select name="field_138_year" id="field_138_year">
                <option value="1911">1911</option>
                <option value="1912">1912</option>
                <option value="1913">1913</option>
                <option value="1914">1914</option>
                <option value="1915">1915</option>
                <option value="1916">1916</option>
                <option value="1917">1917</option>
                <option value="1918">1918</option>
                <option value="1919">1919</option>
                <option value="1920">1920</option>
                <option value="1921">1921</option>
                <option value="1922">1922</option>
                <option value="1923">1923</option>
                <option value="1924">1924</option>
                <option value="1925">1925</option>
                <option value="1926">1926</option>
                <option value="1927">1927</option>
                <option value="1928">1928</option>
                <option value="1929">1929</option>
                <option value="1930">1930</option>
                <option value="1931">1931</option>
                <option value="1932">1932</option>
                <option value="1933">1933</option>
                <option value="1934">1934</option>
                <option value="1935">1935</option>
                <option value="1936">1936</option>
                <option value="1937">1937</option>
                <option value="1938">1938</option>
                <option value="1939">1939</option>
                <option value="1940">1940</option>
                <option value="1941">1941</option>
                <option value="1942">1942</option>
                <option value="1943">1943</option>
                <option value="1944">1944</option>
                <option value="1945">1945</option>
                <option value="1946">1946</option>
                <option value="1947">1947</option>
                <option value="1948">1948</option>
                <option value="1949">1949</option>
                <option value="1950">1950</option>
                <option value="1951">1951</option>
                <option value="1952">1952</option>
                <option value="1953">1953</option>
                <option value="1954">1954</option>
                <option value="1955">1955</option>
                <option value="1956">1956</option>
                <option value="1957">1957</option>
                <option value="1958">1958</option>
                <option value="1959">1959</option>
                <option value="1960">1960</option>
                <option value="1961">1961</option>
                <option value="1962">1962</option>
                <option value="1963">1963</option>
                <option value="1964">1964</option>
                <option value="1965">1965</option>
                <option value="1966">1966</option>
                <option value="1967">1967</option>
                <option value="1968">1968</option>
                <option value="1969">1969</option>
                <option value="1970">1970</option>
                <option value="1971">1971</option>
                <option value="1972">1972</option>
                <option value="1973">1973</option>
                <option value="1974">1974</option>
                <option value="1975">1975</option>
                <option value="1976">1976</option>
                <option value="1977">1977</option>
                <option value="1978">1978</option>
                <option value="1979">1979</option>
                <option value="1980">1980</option>
                <option value="1981">1981</option>
                <option value="1982">1982</option>
                <option value="1983">1983</option>
                <option value="1984">1984</option>
                <option value="1985">1985</option>
                <option value="1986">1986</option>
                <option value="1987">1987</option>
                <option value="1988">1988</option>
                <option value="1989">1989</option>
                <option value="1990">1990</option>
                <option value="1991">1991</option>
                <option value="1992">1992</option>
                <option value="1993">1993</option>
                <option value="1994">1994</option>
                <option value="1995">1995</option>
                <option value="1996">1996</option>
                <option value="1997">1997</option>
                <option value="1998">1998</option>
                <option value="1999">1999</option>
                <option value="2000">2000</option>
                <option value="2001">2001</option>
                <option value="2002">2002</option>
                <option value="2003">2003</option>
                <option value="2004">2004</option>
                <option value="2005">2005</option>
                <option value="2006">2006</option>
                <option value="2007">2007</option>
                <option value="2008">2008</option>
                <option value="2009">2009</option>
                <option value="2010">2010</option>
                <option value="2011" selected="selected">2011</option>
                <option value="2012">2012</option>
                <option value="2013">2013</option>
                <option value="2014">2014</option>
                <option value="2015">2015</option>
                <option value="2016">2016</option>
                <option value="2017">2017</option>
                <option value="2018">2018</option>
                <option value="2019">2019</option>
                <option value="2020">2020</option>
                <option value="2021">2021</option>
                <option value="2022">2022</option>
                <option value="2023">2023</option>
                <option value="2024">2024</option>
                <option value="2025">2025</option>
                <option value="2026">2026</option>
                <option value="2027">2027</option>
                <option value="2028">2028</option>
                <option value="2029">2029</option>
                <option value="2030">2030</option>
                <option value="2031">2031</option>
                <option value="2032">2032</option>
                <option value="2033">2033</option>
                <option value="2034">2034</option>
                <option value="2035">2035</option>
                <option value="2036">2036</option>
                <option value="2037">2037</option>
                <option value="2038">2038</option>
                <option value="2039">2039</option>
                <option value="2040">2040</option>
                <option value="2041">2041</option>
                <option value="2042">2042</option>
                <option value="2043">2043</option>
                <option value="2044">2044</option>
                <option value="2045">2045</option>
                <option value="2046">2046</option>
                <option value="2047">2047</option>
                <option value="2048">2048</option>
                <option value="2049">2049</option>
                <option value="2050">2050</option>
                <option value="2051">2051</option>
                <option value="2052">2052</option>
                <option value="2053">2053</option>
                <option value="2054">2054</option>
                <option value="2055">2055</option>
                <option value="2056">2056</option>
                <option value="2057">2057</option>
                <option value="2058">2058</option>
                <option value="2059">2059</option>
                <option value="2060">2060</option>
                <option value="2061">2061</option>
                <option value="2062">2062</option>
                <option value="2063">2063</option>
                <option value="2064">2064</option>
                <option value="2065">2065</option>
                <option value="2066">2066</option>
                <option value="2067">2067</option>
                <option value="2068">2068</option>
                <option value="2069">2069</option>
                <option value="2070">2070</option>
                <option value="2071">2071</option>
                <option value="2072">2072</option>
                <option value="2073">2073</option>
                <option value="2074">2074</option>
                <option value="2075">2075</option>
                <option value="2076">2076</option>
                <option value="2077">2077</option>
                <option value="2078">2078</option>
                <option value="2079">2079</option>
                <option value="2080">2080</option>
                <option value="2081">2081</option>
                <option value="2082">2082</option>
                <option value="2083">2083</option>
                <option value="2084">2084</option>
                <option value="2085">2085</option>
                <option value="2086">2086</option>
                <option value="2087">2087</option>
                <option value="2088">2088</option>
                <option value="2089">2089</option>
                <option value="2090">2090</option>
                <option value="2091">2091</option>
                <option value="2092">2092</option>
                <option value="2093">2093</option>
                <option value="2094">2094</option>
                <option value="2095">2095</option>
                <option value="2096">2096</option>
                <option value="2097">2097</option>
                <option value="2098">2098</option>
                <option value="2099">2099</option>
                <option value="2100">2100</option>
                <option value="2101">2101</option>
                <option value="2102">2102</option>
                <option value="2103">2103</option>
                <option value="2104">2104</option>
                <option value="2105">2105</option>
                <option value="2106">2106</option>
                <option value="2107">2107</option>
                <option value="2108">2108</option>
                <option value="2109">2109</option>
                <option value="2110">2110</option>
                <option value="2111">2111</option>
              </select>
              <select name="field_138_hour" id="field_138_hour">
                <option value="00">00</option>
                <option value="01">01</option>
                <option value="02">02</option>
                <option value="03">03</option>
                <option value="04">04</option>
                <option value="05">05</option>
                <option value="06">06</option>
                <option value="07">07</option>
                <option value="08">08</option>
                <option value="09">09</option>
                <option value="10">10</option>
                <option value="11">11</option>
                <option value="12" selected="selected">12</option>
                <option value="13">13</option>
                <option value="14">14</option>
                <option value="15">15</option>
                <option value="16">16</option>
                <option value="17">17</option>
                <option value="18">18</option>
                <option value="19">19</option>
                <option value="20">20</option>
                <option value="21">21</option>
                <option value="22">22</option>
                <option value="23">23</option>
              </select>
:              <select name="field_138_minute" id="field_138_minute">
                <option value="00">00</option>
                <option value="01">01</option>
                <option value="02">02</option>
                <option value="03">03</option>
                <option value="04">04</option>
                <option value="05">05</option>
                <option value="06">06</option>
                <option value="07">07</option>
                <option value="08">08</option>
                <option value="09">09</option>
                <option value="10">10</option>
                <option value="11">11</option>
                <option value="12">12</option>
                <option value="13">13</option>
                <option value="14" selected="selected">14</option>
                <option value="15">15</option>
                <option value="16">16</option>
                <option value="17">17</option>
                <option value="18">18</option>
                <option value="19">19</option>
                <option value="20">20</option>
                <option value="21">21</option>
                <option value="22">22</option>
                <option value="23">23</option>
                <option value="24">24</option>
                <option value="25">25</option>
                <option value="26">26</option>
                <option value="27">27</option>
                <option value="28">28</option>
                <option value="29">29</option>
                <option value="30">30</option>
                <option value="31">31</option>
                <option value="32">32</option>
                <option value="33">33</option>
                <option value="34">34</option>
                <option value="35">35</option>
                <option value="36">36</option>
                <option value="37">37</option>
                <option value="38">38</option>
                <option value="39">39</option>
                <option value="40">40</option>
                <option value="41">41</option>
                <option value="42">42</option>
                <option value="43">43</option>
                <option value="44">44</option>
                <option value="45">45</option>
                <option value="46">46</option>
                <option value="47">47</option>
                <option value="48">48</option>
                <option value="49">49</option>
                <option value="50">50</option>
                <option value="51">51</option>
                <option value="52">52</option>
                <option value="53">53</option>
                <option value="54">54</option>
                <option value="55">55</option>
                <option value="56">56</option>
                <option value="57">57</option>
                <option value="58">58</option>
                <option value="59">59</option>
              </select>
            </span>
          </div>
        </span>
      </div>
    </td>
    <td id="right">
      <div class="CLUSTER  ">
        <span class="label">Reposición prehospitalaria:</span>
        <span class="content">
          <div class="ELEMENT ELEMENT_DvQuantity ">
            <span class="label">Duración:</span>
            <span class="content">
(*..*)              <input type="text" name="field_19"/>
              <select name="field_20" id="field_20">
                <option value=""/>
                <option value="h">h</option>
                <option value="min">min</option>
              </select>
            </span>
          </div>
          <div class="CLUSTER  ">
            <span class="label">Tipo:</span>
            <span class="content">
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Suero SF:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_21"/>
                  <input type="hidden" name="field_22" value="ml"/>
ml                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Suero Ringer Lactado:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_23"/>
                  <input type="hidden" name="field_24" value="ml"/>
ml                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Coloides:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_25"/>
                  <input type="hidden" name="field_26" value="ml"/>
ml                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Glóbulos rojos:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_27"/>
                  <input type="hidden" name="field_28" value="ml"/>
ml                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Plasma:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_29"/>
                  <input type="hidden" name="field_30" value="ml"/>
ml                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Plaquetas:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_31"/>
                  <input type="hidden" name="field_32" value="ml"/>
ml                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvQuantity ">
                <span class="label">Cristaloides:</span>
                <span class="content">
(*..*)                  <input type="text" name="field_33"/>
                  <input type="hidden" name="field_34" value="ml"/>
ml                </span>
              </div>
            </span>
          </div>
        </span>
      </div>
      <div class="CLUSTER  ">
        <span class="label">VVPs:</span>
        <span class="content">
          <div class="ELEMENT ELEMENT_DV_COUNT ">
            <span class="label">Número de vías:</span>
            <span class="content">
(
    0
..
    10
)              <input type="text" name="field_13"/>
            </span>
          </div>
          <div class="CLUSTER  multiple">
            <span class="label">VVP:</span>
            <span class="content">
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Topografía:</span>
                <span class="content">
                  <select name="field_14" id="field_14">
                    <option value=""/>
                    <option value="at0006||Antebrazo izquierdo">Antebrazo izquierdo</option>
                    <option value="at0007||Antebrazo derecho">Antebrazo derecho</option>
                    <option value="at0008||Miembros inferiores">Miembros inferiores</option>
                  </select>
                </span>
              </div>
              <div class="ELEMENT ELEMENT_DvOrdinal ">
                <span class="label">Calibre:</span>
                <span class="content">
                  <select name="field_15" id="field_15">
                    <option value=""/>
                    <option value="at0011||14">14</option>
                    <option value="at0012||16">16</option>
                    <option value="at0013||18">18</option>
                    <option value="at0014||20">20</option>
                    <option value="at0015||22">22</option>
                    <option value="at0016||24">24</option>
                  </select>
                </span>
              </div>
            </span>
          </div>
        </span>
      </div>
      <div class="CLUSTER  ">
        <span class="label">VVCs:</span>
        <span class="content">
          <div class="CLUSTER  ">
            <span class="label">VVC:</span>
            <span class="content">
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Yugular interna:</span>
                <span class="content">
                  <select name="field_16" id="field_16">
                    <option value=""/>
                    <option value="at0020||Derecha">Derecha</option>
                    <option value="at0021||Izquierda">Izquierda</option>
                  </select>
                </span>
              </div>
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Subclavia:</span>
                <span class="content">
                  <select name="field_17" id="field_17">
                    <option value=""/>
                    <option value="at0023||Derecha">Derecha</option>
                    <option value="at0024||Izquierda">Izquierda</option>
                  </select>
                </span>
              </div>
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Femoral:</span>
                <span class="content">
                  <select name="field_18" id="field_18">
                    <option value=""/>
                    <option value="at0026||Derecha">Derecha</option>
                    <option value="at0027||Izquierda">Izquierda</option>
                  </select>
                </span>
              </div>
            </span>
          </div>
          <div class="CLUSTER  ">
            <span class="label">VVC:</span>
            <span class="content">
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Yugular interna:</span>
                <span class="content">
                  <select name="field_16" id="field_16">
                    <option value=""/>
                    <option value="at0020||Derecha">Derecha</option>
                    <option value="at0021||Izquierda">Izquierda</option>
                  </select>
                </span>
              </div>
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Subclavia:</span>
                <span class="content">
                  <select name="field_17" id="field_17">
                    <option value=""/>
                    <option value="at0023||Derecha">Derecha</option>
                    <option value="at0024||Izquierda">Izquierda</option>
                  </select>
                </span>
              </div>
              <div class="ELEMENT ELEMENT_DV_CODED_TEXT ">
                <span class="label">Femoral:</span>
                <span class="content">
                  <select name="field_18" id="field_18">
                    <option value=""/>
                    <option value="at0026||Derecha">Derecha</option>
                    <option value="at0027||Izquierda">Izquierda</option>
                  </select>
                </span>
              </div>
            </span>
          </div>
        </span>
      </div>
    </td>
  </tr>
  <tr>
    <td colspan="2" id="bottom"/>
  </tr>
</table>
